APPLICATION TO ATTEND A RECOGNIZED
PUBLIC COMMUNITY COLLEGE BY
COOPERATIVE AGREEMENT
Please choose one: New Request Continued Request
Today’s Date: First & Last Name:
Address:
Telephone Number: E-Mail Address:
IL Community College you wish to attend:
Program you intend to enroll in:
Black Hawk College approves Cooperative Agreements for up to 3 terms (check all that apply below). You must submit
a new application for additional terms. I intend to apply for the following terms:
Summer Fall Spring
List course prefix, course number and title of the course(s) you will be taking for each semester checked above:
I hereby certify that, to the best of my knowledge, the above information is true and complete, without evasion or
misrepresentation. I understand that if facts are found to be otherwise, such discovery may be sufficient cause for rejection of my
request or withdrawal of permission granted.
Signed: Date:
INSTRUCTIONS:
1. Mail the completed form to: Vice President for Instruction
Black Hawk College
6600 34th Avenue, Moline, IL 61265
Or fax form to: Attn: Vice President for Instruction
309-792-8127
Or e-mail the form to: adamss@bhc.edu
This form MUST be completed and returned to the Vice President for Instruction at least 30 days PRIOR to the
beginning of any semester, quarter, or term for which you request support.
2. Black Hawk College will send approved agreements to the college you are applying to attend.
To be completed by a BHC Administrator:
Approved Denied
Vice President for Instruction
